Public Health RN Case Manager - Behavioral Health

Job Title: 4-in-1 Public Health Registered Nurse Case Manager

Full Time Grant Funded

Reports To: Behavioral Health Director

Summary: The Public Health Case Manager functions as an integral member of the medical and behavioral health departments with the aim of improving self-management and clinical outcomes for patients of San Diego American Indian Health Center. The PH RN Case Manager will plan, organize, and coordinate care, targeting individuals at the highest risk and ensuring integrated flow of services. The Case Manager will be responsible for panel and case (individual) management of patients and will work in close proximity with the primary care and behavioral health teams to achieve the desired outcomes.

Essential Duties and Responsibilities:

Support of the mission of the Indian Health Service 4-in-1 grant: Support health promotion and disease prevention programming, immunization services, substance abuse related services, and behavioral health services. Aim is to specifically link these services to the larger infrastructure of the health center to address specific service gaps that may exist.

Develop and implement a patient outreach strategy designed to increase the utilization of the health center's medical services among urban American Indian/Alaskan Natives, resulting in an increase of unduplicated eligible beneficiaries receiving primary care and/or preventive services.

Manage the Immunization Services Program, including: a) participation in Vaccines for Children (VFC) and older adult vaccine programs; b) implementation of health promotion strategies designed to increase overall coverage rates; c) prepare and submit quarterly reports to the National Immunization Reporting System (NIRS).

Collaborate with the Chief Medical Officer/Medical Director/Behavioral Health Director to ensure that processes are in place to collect and evaluate behavioral health screenings (including depression, tobacco, alcohol, and intimate partner violence screens) among primary care patients and manage referrals as appropriate to the behavioral health department or case manager.

Assess mid-year GPRA results as of 3/31/20 each year and consult with the Chief Medical Officer to identify a minimum of three underperforming clinical performance measures that may be improved through implementation of evidence-based strategies to achieve the IHS national targets by the end of the GPRA reporting period (9/30/20). Utilization of population health management tool (I-Care) and electronic health record (RPMS) to collect and manage data for the patient registries.

Ensure services meet guidelines for Government Performance and Results Act (GPRA), Patient-Centered Medical Home (PCMH), Accountable Care Organization (ACO), Health Resources Services Administration (HRSA) and other quality performance initiatives.

Monitor all performance indicators and communicate with medical providers and/or staff regarding which performance indicators are due at the clinic visit (pre-visit preparation).

Actively contact patients within the registries to set up RN case management appointments. In conjunction with patient, develop a written care plan that incorporates patient preferences and functional lifestyle goals; identifies treatment goals; addresses potential barriers; and produces a self-management plan. Set attainable goals using evidence-based practice as the foundation while addressing gaps and /or barriers to care.

Participate in the Diabetes Prevention Program.

Provide member education to assist with self-management goals. Identify barriers to self-management, such as transportation, and make arrangements accordingly.

Active involvement in the community to educate about risk factors for chronic disease, increase community-based screening methodologies, and recruit newly diagnosed individuals to SDAIHC for treatment and management.

Adhere to organizational and departmental policies and procedures.

Perform the clinical and administrative duties necessary to meet the goals and objectives of the grant.

Other duties as assigned by the Chief Medical Officer.

Qualifications:

Education and/or Experience: Public Health Nursing Degree AND Bachelor's degree in nursing from a four year college or university (RN).

Ability to view the patient as a whole person within the context of their family and community.

Behavioral counseling experience.

Excellent interpersonal and communication skills.

Computer and analytic skills to run reports and review data.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Knowledge of utilization management, quality improvement and cost management

The SDAIHC client experience includes using AIDET to develop a strong connection with our patients/clients.

Acknowledge: Greet the patient/client by name. Make eye contact, smile, and acknowledge family or friends in the room.

Introduce: Introduce yourself with your name, skill set, professional certification, and experience. Managing yourself and your colleagues up instill confidence that our patients/clients are in the best place to receive care.

Duration: Give an accurate time expectation for tests, physician arrival, and identify next steps. When this is not possible, give a time in which you will update the patient on progress. When wait exceeds expectation continue to check in with patient/client.

Explanation: Explain step-by-step what to expect next, answer questions, and let the patient/client know how to contact you, such as a extension or phone number.

Thank You: Thank the patient and/or family. Express gratitude to them for choosing SDAIHC for their care, and you appreciate them placing their trust with us. Thank family members for being there to support the patient.

Acknowledgement: The San Diego American Indian Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, ancestry, age, marital status, physical or mental disability, or any other protected class, political affiliation, or belief. Indian preference is given to qualified American Indian candidates to fill vacancies in accordance with the Indian Preference Act of 1934 (Title 25, USC Section 472).